The Diagnosis and Treatment of Tuberculous Infections

The Diagnosis and Treatment of Tuberculous Infections. The American quarterly publication* known as ' International Clinics " forms a valuable addition to any medical library on this side of the Atlantic, and although the majority of contributions to its pages originate in the United States, yet there are many valuable records included of advances made in our own country. In the following note we make

JOINT DISEASE IN CHILDREN.
The Diagnosis and Treatment of Tuberculous Infections.
The American quarterly publication* known as ' International Clinics " forms a valuable addition to any medical library on this side of the Atlantic, and although the majority of contributions to its pages originate in the United States, yet there are many valuable records included of advances made in our own country. In the following note we make particular mention of a post-graduate lecture likely to interest many institutional readers, and given by the Associate Professor in Surgery to the University of Pennsylvania. It forms a good example of the clarity of style and thought with which the highly interesting pages of these volumes are compiled.
In basing our few remarks concerning this condition upon Dr. Ashhurst's words, it is Unnecessary to detail th? accepted modes of entry of the tubercle bacilli to the young organism.
Reaching the cervical, bronchial, ?r mesenteric lymph glands the organisms ultimately find their way into the circulation, and if a suitable soil is found, a locus minoris resistentice., then multiplication and the typical lesions of tuberculosis are produced. It is suggested that the most favourable sites for this process to occur are those Where lymphoid cells exist, and, in young children, the synovial lining of joints, the red bone marrow at points such as the cancellous ends of bones, and m the short bones of the hand and foot, form the ^ost likely and vulnerable spots. Even in these positions., if the local resistance is sufficient, no lesion may develop, but if the natural barriers to infection are for any reason lowered, the result is obvious. Thus it is that one finds, in about onethird of the cases of tuberculous joints, a history of trauma, usually comparatively slight,, precedlng, by a period of several weeks, the development symptoms of tuberculous disease. In view of the frequency with which children sustain slight joint drains, etc., it seems reasonable to assume that, ev?n if it cannot be demonstrated clinically, the child with a tuberculous bone or joint disease has a tuberculous focus somewhere else in its body.
The author makes a great point of the importance referred pain. For example, there is, he says, Scarcely a year passes that one does not see one or more little children who have been treated symptomatically by their family doctors for weeks, sometimes for months, for pains in their stomachs, when a cursory examination of their back shows them to be suffering from tuberculosis of the spine, and demonstrates that the pain is really referred along the intercostal or lumbar nerves. So, also, With hip-joint disease, the pain may be referred to the knee along the obturator nerve. On the other hand, stiffness of a joint may be noticed at once by Parents, it may wear off dining the early part of the ^ay and again become pronounced in the evening.
l-?metimes a joint, painless by day, may produce " starting pains " at ijiglit when the muscles are relaxed, but it is in relatively few cases that attention is at once specifically drawn to the exact site of the infection. Physical Examination.
For this reason, then, it is impossible to insist too strongly that children should always be examined stripped. The presence of clothing inevitably hinders the physician's or nurse's perception of deformity or limitation of movement. Also it is essential to gain the child's confidence in order to watch it carrying out simple unobstructed and unassisted movements. The child should, for instance, stoop to pick up something oil' the floor; if there is spinal disease one may often see him bend his knees and hips, bringing his buttocks almost into contact with the floor rather than flex his spine to stoop forward and pick up the object normally. The spasm of the associated muscles must also be noted and the limitation of movement thereby produced.
It is an axiom insistently put to the medical student, but nevertheless forgotten with ridiculjous frequency, that the only satisfactory way to observe movement limitation is to compare the diseased with the corresponding healthy joint. Details of comparisons which might then be drawn would take us into many pages.
Dr. Ashhurst gives the fullest description of a list of interesting points, all amply illustrated by photographs taken at his clinic. The immediate lesson, however, is that the greatest care is essential in observing the early manifestations. e Once any considerable degree of involvement of bone and cartilage or its destruction has occurred the diagnosis is usually obvious at a glance, but if satisfactory care is to be exercised the condition positively must be detected early, and to do this requires remarkably close observation of the child and its everyday movements.

Treatment.
And as to cure, the author insists that tKe following still holds good. by abolishing all joint friction, because thus both red marrow and synovia become atrophic and even disappear entirely in the event of ankylosis. Where these tissues do not exist it is supposed that tubercle bacilli cannot live, but whatever the true explanation, the facts remain that, apart of course from general constitutional and hygienic treatment, our best methods obtain rest by a combination of fixation and traction of the parts involved. Here again it is obvious that to describe the technical application of this technique would take us into a mass of detailed orthopaedics, and it must suffice to remember the underlying principle of all of it. Operative treatment of the surgical deformities following tuberculous infection are beyond the scope of this note, but it is well to remember that there is always a possibility of lighting up the old infection once more, and we have always to decide whether the patient's disability is so pronounced as to demand surgical relief. Ankylosis is probably the best and surest " cure " of tuberculous arthritis, and, except in the elbow or shoulder, is usually best not interfered with.
It is obvious, therefore, that the treatment of this infection, when it has begun, is inevitably a long and tedious process, and the extreme urgency of early diagnosis lays a duty on nurses and doctors alike when dealing with juvenile cases. If proper facilities are not .at hand transference of Jheir patients to the advantages of a hospital servicie is essential, for there only can the obvious necessity of resisting the beginning of the pathological process be efficiently met.